Report on Medicare Compliance

  1. Commercial Payer, Medicare Telehealth Audits Are Underway, With Some Surprises

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | Author: Nina Youngstrom  | January 18, 2021 

    In an audit twist that shows the prevalence of telehealth services because of COVID-19, some reviews are underway of in-person home infusion, with auditors questioning why home infusion physician practices aren’t delivering more follow-up services by telehealth, an attorney said...

  2. No Surprises Act Limits Out-of-Network Charges; Exception Requires Compliance Oversight

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | Author: Nina Youngstrom  | January 18, 2021 

    Hospitals and health plans soon will be circling each other in another realm—payments and claim denials for services provided out of network—now that Congress has enacted a law on surprise billing. The No Surprises Act,[1] which is part of the 2021 Consolidated Appropriations Act signed by President Trump Dec. 27, protects patients from large or unexpected bills when they’re treated by hospitals, physicians and other providers that don’t participate in their health plans, depending on the circumstances. The law also establishes an arbitration process for providers and payers to settle payment disputes about out-of-network services when they’re at an impasse...

  3. Snapshot of the No Surprises Act: Its Application and the Arbitration Process

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | Author: Nina Youngstrom  | January 18, 2021 

    Here’s a quick look at key provisions of the No Surprises Act, which limits patient liability for services performed by providers that are not in the patient’s health plan (see story, p. 1).[1] This was created by the law firm King & Spalding. Contact attorney John Barnes at jbarnes@kslaw.com...

  4. New Law Gives Entities a Break on HIPAA Fines if Compliance Improved

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | Author: Theresa Defino  | January 18, 2021 

    In July, the HHS Office for Civil Rights (OCR) reached a $25,000 settlement with Agape Health Services, a federally qualified health center in rural Washington, North Carolina,[1]  after initially proposing a $400,000 fine,[2] Clifton Gray III, the chief compliance officer for Agape, told Report on Patient Privacy, RMC’s sister publication. Even at $25,000, the payment—accompanied by a two-year corrective action plan—was “devastating,” Gray said...

  5. CMS to Take Back Money It Returned Under Site-Neutral Payment Policy

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | Author: Nina Youngstrom  | January 18, 2021 

    CMS is taking back money from hospitals for outpatient clinic visits provided in 2019 at excepted off-campus provider-based departments (PBDs) after returning the money when it lost a federal court decision on the site-neutral payment policy introduced in the 2019 Outpatient Prospective Payment System regulation...

  6. CMS Transmittals and Federal Register Regulations, Jan. 8-14, 2021

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | January 18, 2021 

  7. News Briefs: January 18, 2021

    Report on Medicare Compliance Volume 30, Number 2. January 18, 2021  | Author: Nina Youngstrom  | January 18, 2021 

    ◆ Recovery audit contractors (RACs) may soon be auditing positron emission tomography (PET) for initial treatment strategy in oncologic conditions for compliance with medical necessity and documentation requirements. It was added to the list of proposed RAC topics[1] Jan. 5 for outpatient hospital and professional service reviews. CMS also added the first 2021 audit targets to the approved list: Air Ambulance: Medical Necessity and Documentation Requirements,[2] Hospice Continuous Home Care: Medical Necessity and Documentation Requirements,[3] and Ambulance Transport Subject to SNF Consolidated Billing.[4]...

  8. Outlook 2021: COVID-19 Will Shape Compliance Agenda; Other Challenges Also Loom Large

    Report on Medicare Compliance Volume 30, Number 1. January 11, 2021  | Author: Nina Youngstrom  | January 11, 2021 

    The COVID-19 pandemic will continue to set the agenda in compliance and enforcement in 2021 without swallowing it whole. It will be the year of duality, as the virus rages on but vaccines put the nation on the road to recovery, as auditors and enforcers pursue both COVID-19 abuses and more familiar types of overpayments and fraud, and as compliance professionals who are working remotely put one foot back in the office, which may be smaller as some hospitals reduce their real estate footprint. Wherever they are, compliance professionals will have a lot on their plate. New regulations take effect...

  9. Outlook 2021: Expect 'Vigorous' FCA Enforcement; Prosecutor: Don't Back Off Compliance

    Report on Medicare Compliance Volume 30, Number 1. January 11, 2021  | Author: Nina Youngstrom  | January 11, 2021 

    Although there will be new leadership at the Department of Justice (DOJ) and HHS, prosecutors and other attorneys say they have a pretty good feel for what health fraud enforcement will look like in 2021. The new kid on the block will be COVID-19 fraud and abuse, where it joins other recent priorities, including cases involving opioids and electronic health records (EHRs). DOJ and/or the HHS Office of Inspector General (OIG) also are expected to hammer away at kickbacks and substandard care in nursing facilities...

  10. CMS Transmittals and Federal Register Regulations, Dec. 18, 2020-Jan. 7, 2021

    Report on Medicare Compliance Volume 30, Number 1. January 11, 2021  | January 11, 2021 

  11. News Briefs: January 11, 2021

    Report on Medicare Compliance Volume 30, Number 1. January 11, 2021  | Author: Nina Youngstrom  | January 11, 2021 

    ◆ Texas Heart Hospital of the Southwest LLP in Plano, Texas, which is partly owned by physicians, and its subsidiary, THHBP Management Company LLC (together known as Heart Hospital), agreed to pay $48 million to settle false claims allegations, the Department of Justice (DOJ) said Dec. 18.[1] The settlement “resolves allegations that the Heart Hospital violated the Stark Law and Anti-Kickback Statute by requiring physician owners to satisfy the Heart Hospital’s yearly 48 patient-contact requirement in order to maintain ownership in the hospital,” DOJ said. The case was set in motion by two whistleblowers who are former Heart Hospital physicians...

  12. Two Hospitals Pay $8.37M to Settle Case About Psych Certifications, Treatment Plans

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    In separate settlements with the HHS Office of Inspector General (OIG), two Massachusetts hospitals in the same family have agreed to pay a total of about $8.37 million to settle allegations that their inpatient psychiatric units didn’t comply with Medicare requirements for certifications and treatment plans. The units were managed by a third-party contractor, according to the civil monetary penalty settlements, which were obtained through the Freedom of Information Act...

  13. Checklist to Help Ensure Compliant Certifications for Inpatient Psychiatric Hospitalizations

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    Incomplete certifications may derail Medicare claims for inpatient psychiatric hospitalizations.[1] This checklist, which is based on Medicare requirements, was developed by Georgia Rackley, senior clinical specialist with SunStone Consulting in Harrisburg, Pennsylvania. Contact her at georgiarackley@sunstoneconsulting.com...

  14. DRG Window Recoupment Is Coming in Wake of OIG Audit; Similar Item Is Added to Work Plan

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    Some hospitals are adding the long-time compliance risk of the DRG three-day window to their internal work plans and will face Medicare recoupment in the wake of an HHS Office of Inspector General (OIG) May 2020 report[1] that found millions in overpayments for noncompliance. The pressure is mounting because OIG on Dec. 15 added another oldie but goodie with similar overtones to its Work Plan:[2] overpayments to acute-care hospitals for outpatient services provided to inpatients of long-term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities and critical-access hospitals...

  15. With COVID-19 Vaccine OK, Hospitals Turn to Billing, May Use PRF Money

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    Scientists have delivered on COVID-19 vaccines in record time, and now hospitals must sort through the logistical challenges of administering them, as well as billing, coding and other considerations. If reimbursement doesn’t cover the costs associated with the vaccine, hospitals may look to support from the Provider Relief Fund (PRF), although its use will be under the microscope...

  16. Medicare Part B Payments and Codes for COVID-19 Vaccines

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    CMS has posted coding and reimbursement information for administration of the vaccines and the vaccines themselves.[1]...

  17. Moving From Reactive to Proactive Compliance May Reduce Risks

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    When an orthopedic surgeon demanded very generous compensation, the hospital weighed its clinical and business needs against the compliance risks. It had to act fast, because the orthopedic surgeon threatened to go elsewhere. With the clock ticking, the vice president in charge of high-risk arrangements had no time to analyze data, including the orthopedic surgeon’s clinical patterns and productivity, and make an informed hiring recommendation. She crossed her fingers and sent the contract to the CEO for a signature...

  18. CMS Transmittals and Federal Register Regulations, Dec. 11-17

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | December 21, 2020 

  19. News Briefs: December 21, 2020

    Report on Medicare Compliance Volume 29, Number 45. December 21, 2020  | Author: Nina Youngstrom  | December 21, 2020 

    ◆ CMS said Dec. 18 it will audit a sample of hospitals for compliance with price transparency requirements, which take effect Jan. 1, according to MLN Connects.[1] In addition, CMS will investigate complaints submitted to CMS and review “analyses of non-compliance, and hospitals may face civil monetary penalties for noncompliance.” CMS has a website for people to report noncompliance.[2]...

  20. Proposed HIPAA Privacy Rule Doubles Down on Patient Right of Access, Revises NPP

    Report on Medicare Compliance Volume 29, Number 44. December 14, 2020  | Author: Nina Youngstrom  | December 14, 2020 

    In proposed changes to the HIPAA Privacy Rule,[1] the HHS Office for Civil Rights (OCR) conveys there is very little that should come between patients and their protected health information (PHI). The proposed rule, which was announced Dec. 10, focuses on patient access and puts to rest the troublesome issues around direct patient requests for records versus third-party requests. OCR also tweaks the content of the notice of privacy practices (NPPs) and frees covered entities (CEs) from getting patient signatures on them...

  21. With 24/7 Nursing Waiver, CMS Opens Door to Inpatients at Home, Asks States to Play Ball

    Report on Medicare Compliance Volume 29, Number 44. December 14, 2020  | Author: Nina Youngstrom  | December 14, 2020 

    With an individual waiver of round-the-clock nursing care now in reach, hospitals will be able to treat Medicare inpatients at home during the public health emergency (PHE), freeing up beds as cases of COVID-19 surge. The CMS Acute Hospital Care at Home program,[1] announced Nov. 25, adds a new dimension to Hospitals Without Walls, the series of blanket waivers that enable hospitals to treat inpatients in temporary expansion sites during the PHE. Hospitals still have a hurdle at the state level, but in a Dec. 7 letter,[2] CMS Administrator Seema Verma asked governors to get on board by waiving licensure...

  22. Snapshot: A Quick Comparison of What Is and Isn't Waived for CMS's Acute Hospital Care at Home

    Report on Medicare Compliance Volume 29, Number 44. December 14, 2020  | Author: Nina Youngstrom  | December 14, 2020 

    Here’s a shorthand version of many aspects of the Medicare conditions of participation (CoPs) waivers that apply to CMS’s new Acute Hospital Care at Home program[1] during the COVID-19 public health emergency. They are compared to the CoPs that are still in effect. The comparison was prepared by attorney Ann McCullough of Polsinelli in Denver. Contact her at amccullough@polsinelli.com...

  23. Outpatient Therapy Faces Payment Cuts in 2021, Audits Are Underway

    Report on Medicare Compliance Volume 29, Number 44. December 14, 2020  | Author: Nina Youngstrom  | December 14, 2020 

    In a double whammy, outpatient therapy providers are facing a 10% payment cut next year and audits by Medicare administrative contractors (MACs) have resumed even though Targeted Probe and Educate (TPE) is on hold because of the COVID-19 public health emergency (PHE). But there’s good news on the telehealth front for physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs), at least in the short term...

  24. Sample Form: Ensuring Patient Status Is Correct for Medicare, Other Payers

    Report on Medicare Compliance Volume 29, Number 44. December 14, 2020  | Author: Nina Youngstrom  | December 14, 2020 

    Here’s a form to help ensure physicians document patient status, including inpatient or observation, for surgeries. “This form fulfills all the items on the wish list of the hospital utilization review staff,” said Ronald Hirsch, M.D., vice president of R1 RCM. “It indicates the HCPCS code of the planned procedure, which is necessary to determine the correct status for many payers; it provides prior authorization information to ensure the payer has approved the procedure; and it provides a clear status designation with need for a bed if appropriate. A signed form also serves as an order for inpatient admission, and...

  25. CMS Transmittals and Federal Register Regulations, Dec. 4-10

    Report on Medicare Compliance Volume 29, Number 44. December 14, 2020  | December 14, 2020